A.D. 1890.]
VACCINATION,
[No. 2.
675
and that I have recommended the postponement of the vaccination until the
day of
Dated the
1
day of
4
(Signed.)
A. B.,
[Medical Practitioner or Public Vaccinator, as the case
may be.]
FORM NO. 3.
Certificate of Insusceptibility of Successful Vaccination.
I, the undersigned, hereby certify that I am of opinion that
of
Dated the
aged
day of
is insusceptible of Vaccine Disease.
I
(Signed)
A. B.,
[Medical Practitioner or Public Vaccinator, as the case
may be.]
FORM No. 4.
Register of Public Vaccinator.
Public Vaccinator's Register at
Station.
No. of Case.
Source of lymph.
Name and Address
of Person, or Parent/Guardian.
In case of re-vaccination
of Persons of 14 and upwards successfully vaccinated in early life, mark R.
Date of Birth.
Initials
of Operator.
Date of Vaccination.
Result.
Successful.
Unsuccessful.
Date of Inspection.
With particulars, if successful, of No. of vesicles that
have taken.
Section 9.
Section 12.